Policies & Procedures

I always recommend facilities create at least four Policies & Procedures (or handbooks) to make available to all staff/caregivers and administration.  Medication Management and Administration policies are especially important because it’s a serious and big responsibility. Topics should include, but are not limited to:

  • Practitioner’s Orders
  • Medication Packaging
  • Reordering Medications Process
  • Medication Storage
  • Medication Documentation
  • Controlled Medication
  • Psychotropic Medication
  • Medication Errors
  • Medication Refusals
  • Resident Absences
  • Annual Reviews
  • Disposal of Medications

Emergency Preparedness is another important one.  Staff/caregivers should all know how to initiate the crisis management plan if they ever find themselves in an emergency.  I recommend including the following topics, at a minimum, in your policies and procedures: total evacuation locations, home environment, emergency food supply, winter storms, shelter-in-place, flood procedures, gas leak procedures, water shortages, electrical power outages, explosion procedures, bomb threats, chemical spills procedure, fire emergencies, and a post-crisis evaluation.

Don’t forget that there are other policies and procedures, especially those specific to your facility, which are of great importance.  Be sure that you have everything in place for not only your staff, but for your residents, too.


Resident Care and Services

Your services need to be designed and provided to allow the residents to increase or maintain independence.  They should teach and provide opportunities for the residents to increase their skills or to minimize natural decline in the ability to make wants and needs known.  The residents need the teaching and providing of opportunities to increase their abilities to get along with others and to strengthen personal relationships.

Staff should encourage and provide training for, as a part of the treatment plan, each resident to be responsible for the upkeep of his or her personal space and belongings.  This may include making their bed, dusting, sweeping, doing their own laundry, any additional household chores that may be assigned, meal preparation, etc.  Try a general “home chore schedule” and don’t forget to provide training in dressing, grooming, bathing, and eating as needed.  Note: These areas should be included in the resident’s ISP.

Residents should be allowed to set and meet goals improving their sense of self-confidence and self worth.  Further, residents should be encouraged to develop and/or maintain a meaningful level of community participation, as well as maintaining or improving on their level of independent functioning consistent with their individual abilities.

You should incorporate programs into an environment that provides for the integration of diverse physical, mental, social, and emotional expression.  Staff should teach and provide opportunities to increase the residents’ skills in grooming, hygiene, meal preparation, housekeeping tasks, budgeting, enhancement of social interaction abilities, counseling, community awareness experiences, medication management and symptom management, and evaluation.

Don’t forget to include all areas in the resident’s ISP and create attainable goals for them to achieve!

Resident Discharge Planning

Without discharge planning and proper relocation procedures (especially with developmentally disabled, elderly, and emotionally disturbed residents), relocation stress syndrome may develop.  Transferring from one environment to another causes physiological and psychological impairment that is actually known to cause serious illness (and can even be fatal).  However, the good news is, a change in routine and this syndrome can be mitigated with proper transition.

A facility may not discharge involuntarily unless any of the following apply:

  • The resident may initiate transfer or discharge at any time (within the terms of the admission/service agreement) as long as they are not on a Chapter 51 or a Chapter 55.
  • If a resident is incompetent, as found via Chapter 54, protests his or her stay, the facility must notify the care team and county protective services agency to obtain determination regarding whether or not to discharge.

The facility is not to discharge voluntarily, unless any of the following apply:

  • A 30-day written advance notice is give to the resident and their respective care care team, as well as the reason for the discharge (and possible alternatives).
  • The home provides assistance in relocating the resident and ensures that the new home or living arrangement is suitable to meet the needs of the resident before actually discharging them.

Note: There are reasons acceptable for involuntary discharge:

  • Nonpayment of charges as long as there is a reasonable opportunity to pay.
  • Care is required beyond what the facility can provide.
  • The resident requires care above and beyond the home’s program statement and terms of the admission/service agreement.
  • The resident requires medical care that the home cannot provide.
  • There is an immediate risk of serious harm to the health, safety, or welfare to the resident, other residents, or staff as documented (in the resident’s record).

What should the administrator do to help ease the adjustment?

  • Promptly inform the resident, i.e. provide the 30-day notice.
  • Assess the needs and preferences of the resident. Do not coerce, bribe, or retaliate.
  • Provide a tour; provide options (written and verbally); explain the benefits… and even the cons.
  • Allow them to ask questions; listen to their concerns.
  • Involve their care team.
  • Be sure to help them pack their belongings and try to make their new area similar to their old area.
  • Be sure to have their needs met at the new placement.
  • Monitor signs for added stress regarding the move.
  • Keep in mind their rights!
  • Prepare appropriate documentation and maintain all necessary documentation.
  • Orient staff appropriately.

Just remember that the facility is the resident’s home and moving is a “big deal” for them.  Make the move as comfortable as possible and display empathy throughout the entire process.


A resident change in condition is not only a “change” it is a process.

Many professionals require certain tools to do a job well.  As a caregiver, your valuable tool is observation.  By simply being attentive, you can gain a better understanding of how your residents feel and are able to recognize how their health, emotional, and social needs change.  You serve as the resident’s advocate and, in addition, fellow caregivers rely on you to observe and report any changes in a resident’s condition.

All caregivers are responsible for recognizing any changes with a resident and how to respond to those changes (it is not only your supervisor that is held accountable).  A change in condition is something different than what previously existed.  Significant change may mean one or more of the following:

  • Decline in a resident’s medical condition that results in long-term impairment
  • Decline in 2 or more activities of daily living
  • A pronounced decline in cognitive abilities or communication
  • Decline in behavior or mood to the point where things have become problematic

Resident documenting is important especially in regards to changes in condition.  The facility must notify the healthcare professional of the change in condition.  Document these changes and the healthcare visit as part of the resident’s record.  At all times, the caregivers must protect the rights and safety of the residents.  In order to do so effectively and properly, we must:

  • Fill out the Significant Change in Health Screening Instrument (DHS Form #F-62370).
  • Notify the physician and/or bring the resident to a medical professional (be sure to document these interactions and/or appointments).
  • Contact the treatment team (including the guardian or person responsible for the resident) and be sure to document and file the appropriate paperwork based on their policies and requests.
  • Fill out an Incident/Accident Report (if applicable).
  • Review and revise the Individual Service Plan (ISP) based on the assessment you will be conducting regarding the change (i.e., when there is a change in a resident’s needs, abilities, and physical or mental condition).
  • Review your written facility policy and procedure regarding the steps to take when there is an observed change of condition.
  • Report the significant change in condition to the Department.

It is a process.  It may seem time consuming.  It may seem tedious.  It may even seem overwhelming.  However, the ultimate goal is the proper care of your residents and it is imperative that you meet that goal.  **This was published in WALA’s newsletter.  Become a member now to read more fantastic articles!!


What exactly needs to be included in the Individual Service Plan??  The most important and main things we need to include are the (1) current status and observations; (2) services provided; (3) desired outcomes and measurable goals; and (4) providers.  It is important to note that the provider will often include staff, but will also sometimes include the physician, administrator, therapist, nutritionist, etc. based on the resident’s needs and wants.  Though the providers will vary by section, it is imperative to include who is responsible for delivering care to the resident.

Actual specifics will vary by population and by resident, but here is a general guide:

  • Personal care
    • Eating (including Special Diet and Choking Hazard)
    • Basic ADLs (including Oral Care, Dressing, Grooming, Bathing)
    • Toileting
  • Behavior Patters
    • Wandering/Elopement
    • Self-Abusive Behavior and/or Suicidal Tendencies
    • Property Destruction
    • Emergency Evacuation
    • Medication Compliance
    • Coping Skills/Mechanisms
    • Isolating
    • Lying
    • Manipulation
    • Stealing
    • Alcohol/Drug Dependence
    • Negative Attention Seeking
    • Sexual Deviation/Problems
    • Water Intoxication
    • Impulsivity
  • Physical Health
    • General Health
    • Chronic, Short-Term, and Recurring Illnesses
    • Physical Disabilities/Limitations
    • Hearing, Eyesight, and Dental
    • Nursing Procedures
  • Mental and Emotional Health
    • Self-Concept
    • Maturation
    • Attitude
    • Interaction with Others
    • Aggressive/Combative
    • Verbal Abuse/Physical Aggression
    • Anxiety
    • Obsessive-Compulsiveness
    • Insight
  • Social Participation
    • Interpersonal Relationships
    • Leisure Time Activities
    • Family Contacts
    • Community Integration
    • Religious and Other Group Activities
  • Independent Living Skills
    • Educational and Vocational Skills
    • Money Management
    • Communication Skills
    • Food/Meal Preparation
    • Community Outings
    • Instrumental ADLs (including Household Chores, Personal Room Upkeep, and Personal Laundry)

Also included must be the resident’s capacity for self-direction, as well as their capacity for self-care.  I know this list seems long and daunting, but things to remember… this list does not need to be included in every ISP… many items will not pertain to some of your residents.  Further, remember that once your ISP is complete, you will most likely not need to re-do the entire ISP.   Every year (for CBRFs) and every six-months (for AFHs), you will need to complete updates.

In addition, the entire treatment team must be involved in the completion of the ISP.  I recommend that you document what goals the resident AND the treatment team believe would be appropriate to include in the resident’s ISP.  Lastly, be sure to obtain a “signature and date” for each member of the treatment team (including the resident) acknowledging the ISP.


All too often, facilities do not understand the importance of monitoring and documenting the use of PRN psychotropic medications.  I am often asked, what constitutes a psychotropic medication? What is the difference between an antipsychotic and a psychotropic medication?  A psychotropic medication is any medication prescribed to treat a psychiatric disorder, a medication capable of affecting the mind, behavior, or emotions.  Common psychotropic medications include: antipsychotics, antidepressants, antianxiety medications, and mood stabilizers.

Not only do we need to monitor the resident while they are on a PRN psychotropic medication, we also need to document this in their Individual Service Plan (ISP).  The resident’s ISP must include the rationale for use and a detailed description of the behaviors which indicate the need for the medication.  Why is the resident taking the medication?  What behaviors are they displaying that constitute the need?  In addition, the administrator (or someone designated by the administrator) is required to monitor the following every month:

  • presence of significant adverse side effects (monitor and even ask the resident if they are exhibiting side effects that staff may not notice)
  • use for discipline for staff convenience (are staff administering it for reasons other than what it is prescribed)
  • contrary to the intended use and to the ISP (are residents requesting it for other than what it’s prescribed, for example)

I recommend creating a form for each resident’s file that you can “sign off on” and add notes with all of this information.  Are you having difficulty determining whether or not a resident is using their PRN psychotropic medication for the right reasons?  Check the script/prescription (which should always be in the resident’s file) and/or the specific medication information (which also should be in the resident’s file).  Others great references include medication drug books, your pharmacist, and your resident’s psychiatrist.


Infection Control

Did you know?  Your facility is required to have infection control policies and procedures in place per the CDC (Centers for Disease Control and Prevention) and OSHA (Occupational Safety and Health Administration) as a health care facility.  Within these policies and procedures comes the need for an Exposure Control Plan, which I find that a lot of facilities fail to include.  

An Exposure Control Plan is a written program outlining the protective measures that your facility takes to eliminate or minimize your exposure to blood or other potentially infectious materials.  The facility must conduct an Exposure Determination to identify job classifications, as well as tasks and procedures in which employees are at potential risk of exposure.  

An Exposure Control Plan includes engineering controls, work practice controls, and personal protective equipment.  OSHA requires that all employees of any health care facility (including assisted living facilities be trained in standard precautions and bloodborne pathogens – including continuing education). ALT Services offers a Bloodborne Pathogens course solely online.  This course covers all of this information and more. Visit www.altservices.org to register or more more information.  Happy caregiving!